Medicare Supplement Insurance Approved Policies List 2015

Transcription

1 Medicare Supplement Insurance Approved Policies List 2015 For more information on health insurance call: MEDIGAP HELPLINE This is a statewide toll-free number set up by the Wisconsin Board on Aging and Long Term Care and funded by the Office of the Commissioner of Insurance to answer questions about health insurance and other health care benefits for the elderly. It has no connection with any insurance company. State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI OCI's Web Site: oci.wi.gov Deaf, hearing, or speech impaired callers may reach OCI through WI TRS. PI-010 (R 03/2015)

2 The mission of the Office of the Commissioner of Insurance... Leading the way in informing and protecting the public and responding to their insurance needs. If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, contact the Office of the Commissioner of Insurance (OCI). To file a complaint online or to print a complaint form: OCI's Web Page oci.wi.gov Phone (608) (In Madison) or (Statewide) Mailing Address Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI Electronic Mail [email protected] Please indicate your name, phone number, and address. Deaf, hearing, or speech impaired callers may reach OCI through WI TRS This list contains information on Medicare supplement insurance policies approved by the Office of the Commissioner of Insurance (OCI). It includes only policies currently being sold in Wisconsin. The companies shown in this list have agreed to be listed. Group policies sold through employers are not included in this list. There are companies that currently sell Medicare supplement insurance policies approved by OCI that have chosen not to be included in the list. Premiums for the policies on the list are as of January 1, 2015, unless noted, and may change throughout the year. This list is updated on an annual basis. For more detailed information on Medicare and Medicare supplement insurance, visit our Web site or contact OCI and request a copy of the booklet, Wisconsin Guide to Health Insurance for People with Medicare. 2

3 Table of Contents Page Definitions... 5 Individual Medicare Supplement Policies Traditional Insurers... 6 Aetna Life Insurance Company... 7 American Continental Insurance Company... 9 American Republic Corp. Insurance Company American Republic Insurance Company American Retirement Life Insurance Company Blue Cross Blue Shield of Wisconsin Central States Indemnity Company of Omaha Colonial Penn Life Insurance Company Combined Insurance Company of America Family Life Insurance Company Gerber Life Insurance Company Globe Life and Accident Insurance Company Government Personnel Mutual Life Insurance Company Gundersen Health Plan, Inc Humana Insurance Company Liberty National Life Insurance Company Mutual of Omaha Insurance Company Order of United Commercial Travelers of America Pekin Life Insurance Company Physicians Mutual Insurance Company Reserve National Insurance Company Standard Life and Accident Insurance Company State Farm Mutual Automobile Insurance Company Sterling Life Insurance Company Thrivent Financial for Lutherans United American Insurance Company UnitedHealthcare Insurance Company (SecureHorizons) Western Catholic Union Wisconsin Physicians Service Insurance Corporation Group Medicare Supplement Policies Traditional Insurers UnitedHealthcare Insurance Company (AARP)

4 Medicare Supplement Policies Medicare Select Dean Health Plan, Inc Group Health Cooperative of South Central Wisconsin Health Tradition Health Plan MercyCare HMO, Inc Physicians Plus Insurance Corporation Security Health Plan of Wisconsin, Inc Unity Health Plans Insurance Corporation Medicare Cost Insurance Dean Health Plan, Inc HealthPartners Insurance Company Medica Insurance Company Medical Associates Clinic Health Plan of Wisconsin

5 Definitions Attained age: This means that as you age your premiums will change to meet your age range and your premiums will become higher. Health history: Health questions may be asked if you are enrolling at a time other than the open enrollment period. Questions may ask for limited information or may ask for detailed information about your health. Issue age: Premiums are set at the age you are when you buy the policy and will not increase because you get older. Premiums may increase for other reasons. Open enrollment period: A one-time-only six-month period when you can buy any Medicare supplement policy you want that is sold in Wisconsin. It starts when you sign up for Medicare Part B and you are age 65 or older. You cannot be denied coverage or charged more due to present or past health problems during this time period. Preexisting condition: A medical condition diagnosed or treated up to six months prior to the purchase of an insurance policy. Medicare supplement policies may impose up to a 180- day waiting period before coverage for that condition begins. Tobacco rates: If you use tobacco, an insurance company may charge you more for your insurance policy. However, this higher rate cannot be applied if you are enrolling during your open enrollment period. Waiting period: The time between the effective date of your Medicare supplement insurance policy and the date the insurance company or Medicare health plan is required to begin paying benefits for preexisting conditions. Preexisting waiting periods may not last longer than six months. 5

6 INDIVIDUAL MEDICARE SUPPLEMENT POLICIES TRADITIONAL INSURERS 6

7 Aetna Life Insurance Company 800 Crescent Centre Drive, Suite 200 Franklin, TN ( Consumer Service Telephone No Form No. GR WI 01 First-Year Commission: 17% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , 534 Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $5, Under 65 $6, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ , , Rates effective January

8 Aetna Life Insurance Company (continued) Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Area 1: $48.00 for all ages Area 2: $42.00 for all ages Area 1: $20.00 for all ages Area 2: $17.00 for all ages Area 1: $20.00 for all ages Area 2: $17.00 for all ages Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 8

9 American Continental Insurance Company 800 Crescent Centre Drive, Suite 200 Franklin, TN ( Consumer Service Telephone No Form No. ACIMSP14BC WI First-Year Commission: 21% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $4, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ Rates effective January

10 American Continental Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Additional Home Health Visits: Foreign Travel Emergency: Area 1: $38.00 for all ages Area 2: $33.00 for all ages Area 1: $32.00 for all ages Area 2: $28.00 for all ages Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Multi-policy household discount offered. 10

11 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3103AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

12 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $3, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $

13 American Republic Corp. Insurance Company (continued) Area 4 Area 5 Area 6 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $24.48 $21.36 $24.48 $21.36 $24.48 $ Area 4 Area 5 Area 6 Under 65 $24.48 $21.36 $24.48 $21.36 $24.48 $ Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Age: Under 65 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. 13

14 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3120AC-WI, A3121AC-WI First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Annual Premium - Basic Policy Premiums are based on attained age. Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Rates effective January

15 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $2, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $1, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $1, $1, Under 65 $1, $1, , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. 15

16 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , ,

17 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 5 Area 5 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 4 Area 5 Area 6 Under 65 $ $ $ $ $ $

18 American Republic Corp. Insurance Company (continued) Part B Deductible ($147): Part B Excess Charges: Not Covered Not Covered Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Not Covered Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. 18

19 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3098AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Annual Premium - High Deductible Plan Premiums are based on attained age. Area 1 Area 2 Age Male Female Age Male Female Under 65 $1, $1, Under 65 $1, $1, , , , , , , , , , , , Area 3 Area 4 Under 65 $1, $1, Under 65 $1, $1, , , , , , , Area 5 Area 6 Under 65 $1, $1, Under 65 $1, $1, , , , , Rates effective January

20 American Republic Corp. Insurance Company (continued) You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 20

21 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3158AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $6, $4, Under 65 $7, $5, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Rates effective January

22 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $4, , , , , , , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $6, $4, Under 65 $7, $5, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $4, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 7 Area 7 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , ,

23 American Republic Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 4 Area 5 Area 6 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 7 Age Male Female Under 65 $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Male Female Age: Under 65 $24.48 $ Additional Home Health Care: Age: Under 65 $

24 American Republic Insurance Company (continued) Foreign Travel Emergency: Age: Under 65 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 24

25 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3160AC-WI, A3159AC-WI First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Annual Premium - Basic Policy Premiums are based on attained age. Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Rates effective January

26 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , Area 7 Area 7 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , ,

27 American Republic Insurance Company (continued) You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , ,

28 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 5 Area 5 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 7 Area 7 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Not Covered Not Covered Not Covered Additional Home Health Care: Age: Under 65 $

29 American Republic Insurance Company (continued) Foreign Travel Emergency: Not Covered Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 29

30 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3161AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Annual Premium - High Deductible Plan Premiums are based on attained age. Area 1 Area 2 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , Area 3 Area 4 Under 65 $2, $2, Under 65 $2, $1, , , , , , , , , , , Area 5 Area 6 Under 65 $2, $2, Under 65 $2, $1, , , , , , , , , , , Rates effective January

31 American Republic Insurance Company (continued) Area 7 Under 65 $2, $2, , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 31

32 American Retirement Life Insurance Company Lakeline Blvd., Suite 100 Austin, TX Consumer Service Telephone No Form No. AR-BASC-WI First-Year Commission: 13.5% - 27% Waiting Period: None Area 1: Zip Codes Area 2: Zip Codes Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ Rates effective January

33 American Retirement Life Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $50.71 $44.11 $58.97 $ Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female Under 65 $37.06 $32.24 $43.09 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Part A Deductible (50%) offered. 33

34 Blue Cross Blue Shield of Wisconsin (dba Anthem Blue Cross and Blue Shield) P.O. Box 9063 Oxnard, CA ( Consumer Service Telephone No Form No. WPPLANBASICM(09)-WI First-Year Commission: 12% Waiting Period: 6 Months Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $6, Under 65 $8, $8, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $5, Under 65 $7, $7, , , , , , , , , , , , , , , , , , , , , Rates effective January

35 Blue Cross Blue Shield of Wisconsin (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $1, $1, $1, $1, $1, $1, Part B Deductible ($147): Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $96.24 $88.08 $81.84 $93.36 $

36 Blue Cross Blue Shield of Wisconsin (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 36

37 Central States Indemnity Company of Omaha P.O. Box Clearwater, FL ( Consumer Service Telephone No Form No. CSBASWI Waiting Period: None First-Year Commission: Varies Premiums are based on attained age. Area 1: Zip Codes Area 2: Zip Codes , 544, 549 Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $2, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective February

38 Central States Indemnity Company of Omaha (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $94.00 $96.00 $85.00 $83.00 $ Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $99.00 $86.00 $89.00 $77.00 $77.00 $ Part B copayment or coinsurance rider offered. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Part A Deductible (50%) offered. 38

39 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL-GR-A830 First-Year Commission: 16% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $6, Under 65 $7, $7, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $6, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $1, $ $ $ Rates effective January

40 Colonial Penn Life Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Part B copayment or coinsurance rider offered. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 40

41 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL -GR-A831, CPL-GR-A832 First-Year Commission: 16% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Rates effective January

42 Colonial Penn Life Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $4, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Annual Premium - Optional Benefits Not Covered Not Covered Not Covered Additional Home Health Care: Area 1 Area 2 Foreign Travel Emergency: Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Not Covered Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. 42

43 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL-GR-A834 First-Year Commission: 10% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - High Deductible Plan Area 1 Area 2 Age Male Female Age Male Female Under 65 $1, $1, Under 65 $1, $1, , , , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. Rates effective January

44 Combined Insurance Company of America 1000 Milwaukee Avenue Glenview, Illinois ( Consumer Service Telephone No Form No First-Year Commission: 13% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ Part B Deductible ($147): Rates effective January 2015 $ for all ages, all areas 44

45 Combined Insurance Company of America (continued) Part B Excess Charges: $39.69 for all ages, all areas Additional Home Health Care: Age Area 1 Area 2 Under 65 $ $ Foreign Travel Emergency: $29.58 for all ages, all areas Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. 45

46 Family Life Insurance Company P.O. Box Houston, TX ( Consumer Service Telephone No Form No. MSAA200810WI First-Year Commission: 29% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , 530(00,05,07,08,12,17,22,24,29,33,37,46,51,52,72,76,89,92, 97), 531(00,02,04,08-10,22,26,30,32,40-44,46,50,51,54,58,59,71) Area 2: All other Zip Codes beginning with 530 and 531, , 544, 549 Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $5, Under 65 $8, $7, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $4, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Rates effective January

47 Family Life Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $1, $1, $1, $1, $1, $1, Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $

48 Family Life Insurance Company (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $97.00 $ $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Multi-policy household discount offered. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 48

49 Gerber Life Insurance Company P.O. Box 2271 Omaha, NE Consumer Service Telephone No Form No. MTG First-Year Commission: 28% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , Area 2: Zip Codes 530(01-04,06,09-11,13-16,18-21,23,26-27,29,31-32,34-36,38-40,42, 44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, , 544, 549 Area 3: Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82,86-89,94), 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $6, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Rates effective January

50 Gerber Life Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $73.60 $64.03 $80.96 $70.44 $88.32 $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $40.92 $35.60 $45.01 $39.16 $49.11 $

51 Gerber Life Insurance Company (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $35.29 $30.70 $38.82 $33.77 $42.34 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. 51

52 Globe Life and Accident Insurance Company 3700 South Stonebridge Drive P.O. Box 8080 McKinney, TX ( Consumer Service Telephone No Form No. GMC4810 Waiting Period: 60 Days First-Year Commission: None Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age: Under 65 $ Part B Deductible ($147): $ for all ages Part B Excess Charges: Age: Under 65 $ Additional Home Health Care: $7.00 for all ages Foreign Travel Emergency: Age: Under 65 $ Different premiums for each age between age 65 and 85. Rates effective January

53 Government Personnel Mutual Life Insurance Company P.O. Box 2271 Omaha, NE ( Consumer Service Telephone No Form No. MTP First-Year Commission: 15% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , Area 2: Zip Codes 530(01-04,06,09-11,13-16,18-21,23,26-27,29,31-32,34-36,38-40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, , 544, 549 Area 3: Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82, 86-89,94), 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

54 Government Personnel Mutual Life Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $87.80 $76.39 $96.58 $84.02 $ $

55 Government Personnel Mutual Life Insurance Company (continued) Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $38.52 $33.51 $42.38 $36.86 $46.23 $ Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $27.25 $23.71 $29.97 $26.08 $32.69 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. 55

56 Gundersen Health Plan, Inc South Avenue La Crosse, WI (myseniorchoice.org) Consumer Service Telephone No Form No WI_MedSupp.CERT First-Year Commission: 15% Waiting Period: None Premiums are based on attained age. Area 1: Buffalo, Crawford, Grant Jackson, La Crosse, Monroe, Richland, Sauk, Trempealeau, and Vernon counties Area 2: Milwaukee, Ozaukee, Washington, Waukesha, Racine, and Kenosha counties Area 3: All other Wisconsin counties Area 4: Policyholders who relocate out of state Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $5, , , , , , , , , , , Area 3 Area 3 Under 65 $3, Under 65 $4, , , , , , , , , , , Rates effective January

57 Gundersen Health Plan, Inc. (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $4, Under 65 $6, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Area 3 Area 4 Under 65 $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Under 65 $ $ $ $ Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Under 65 $ $ $ $

58 Gundersen Health Plan, Inc. (continued) Foreign Travel Emergency: Age Area 1 Area 2 Area 3 Area 4 Under 65 $ $ $ $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. 58

59 Humana Insurance Company 500 West Main Street Louisville, KY ( Consumer Service Telephone No Form No. WI-MESM10 BASIC First-Year Commission: 8% Waiting Period: 90 Days Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: All other Wisconsin counties Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

60 Humana Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $

61 Humana Insurance Company (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $35.64 $35.64 $30.12 $30.12 $31.80 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 61

62 Humana Insurance Company 500 West Main Street Louisville, KY ( Consumer Service Telephone No Form No. WI-MESM1050; WI-MESM1025 First-Year Commission: 8% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: 90 Days Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: All other Wisconsin counties Annual Premium - 50% Cost-Sharing Plan Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , Rates effective January

63 Humana Insurance Company (continued) You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. 63

64 Humana Insurance Company (continued) Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Not covered Not covered Not covered Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Foreign Travel Emergency: Not covered Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 64

65 Humana Insurance Company (Healthy Living) 500 West Main Street Louisville, KY ( Consumer Service Telephone No Form No. WI-MESHL BASIC First-Year Commission: 8% Waiting Period: 90 Days Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: All other Wisconsin counties Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

66 Humana Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $

67 Humana Insurance Company (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $34.20 $34.20 $28.92 $28.92 $30.48 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 67

68 Humana Insurance Company (Healthy Living) 500 West Main Street Louisville, KY ( Consumer Service Telephone No Form No. WI-MESHL50, WI-MESHL25 First-Year Commission: 8% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: 90 Days Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: All other Wisconsin counties Annual Premium - 50% Cost-Sharing Plan Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Rates effective January

69 Humana Insurance Company (continued) You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - 25% Cost-Sharing Plan Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. 69

70 Humana Insurance Company (continued) Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Additional Home Health Care: Annual Premium - Optional Benefits Not covered Not covered Not covered Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Foreign Travel Emergency: Not covered Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 70

71 Liberty National Life Insurance Company 3700 South Stonebridge Drive P.O. Box 8080 McKinney, TX ( Consumer Service Telephone No Form No. LMC4810 First-Year Commission: 35% Waiting Period: 60 Days Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Age Male Female Age Male Female Under 65 $5, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Male Female Under 65 $ $ Part B Deductible ($147): $ for all ages Part B Excess Charges: Age Male Female Under 65 $16.00 $ Rates effective January

72 Liberty National Life Insurance Company (continued) Additional Home Health Care: Male Female For all ages $10.00 $9.00 Foreign Travel Emergency: Age Male Female Under 65 $ 2.00 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and

73 Mutual of Omaha Insurance Company Mutual of Omaha Plaza Omaha, NE ( Consumer Service Telephone No Form No. MM First-Year Commission: 15% Waiting Period: None Premiums are based on attained age. Area 1 Zip Codes , Area 2 Zip Codes 530(01-04,06,09-11,13-16,18-21,23,26-27,29,31-32,34-36,38-40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, , 544, 549 Area 3 Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82,86-89,94), 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Rates effective January

74 Mutual of Omaha Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $38.79 $34.88 $47.28 $42.51 $42.42 $ Additional Home Health Care: $18.00 for all ages, all areas Foreign Travel Emergency: $18.00 for all ages, all areas Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 74

75 Order of United Commercial Travelers of America 1801 Watermark Drive, Suite 100 Columbus, OH ( Consumer Service Telephone No Form No. MSAA2010 WI First-Year Commission: 29% Waiting Period: None Premiums are based on attained age. Area 1 Zip Codes starting with , and 534 Area 2 Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $5, Under 65 $9, $8, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $4, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Age Male Female Male Female Under 65 $1, $1, $1, $1, , , Rates effective January

76 Order of United Commercial Travelers of America (continued) Part B Deductible ($147): Area 1: $ for all ages Area 2: $ for all ages Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. 76

77 Pekin Life Insurance Company 2505 Court Street Pekin, IL ( Consumer Service Telephone No Form No. H42 First-Year Commission: 17% Waiting Period: 180 Days Premiums are based on attained age. Area 1: Zip Codes , Area 2: Zip Codes , , 549 Area 3: Zip Code 530 Area 4: Zip Codes , 534 Area 5: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2, Under 65 $2, , , , , , , , , , , Area 2 Area 2 Under 65 $2, Under 65 $3, , , , , , , , , , , Area 3 Area 3 Under 65 $2, Under 65 $3, , , , , , , , , , , Rates effective January

78 Pekin Life Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $2, Under 65 $3, , , , , , , , , , , Area 5 Area 5 Under 65 $2, Under 65 $3, , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $21.00 $22.00 $23.00 $25.00 $

79 Pekin Life Insurance Company (continued) Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $25.00 $25.00 $25.00 $25.00 $ Foreign Travel Emergency: $2.00 for all ages, all areas Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. 79

80 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P235 First-Year Commission: 24% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Area 3 Area 3 Under 65 $3, Under 65 $4, , , , , , , , , , , Rates effective January

81 Physicians Mutual Insurance Company (P235 Attained Age continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $3, Under 65 $5, , , , , , , , , , , Area 5 Area 5 Under 65 $4, Under 65 $5, , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $ $ $ $ $

82 Physicians Mutual Insurance Company (P235 Attained Age continued) Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $37.44 $39.96 $42.48 $44.88 $ Foreign Travel Emergency: Age: Under 65 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 82

83 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P235 First-Year Commission: 24% Waiting Period: None Premiums are based on issue age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Area 3 Area 3 Under 65 $3, Under 65 $4, , , , , , , , , , , Rates effective January

84 Physicians Mutual Insurance Company (P235 Issue Age continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $3, Under 65 $5, , , , , , , , , , , Area 5 Area 5 Under 65 $4, Under 65 $5, , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $ $ $ $ $

85 Physicians Mutual Insurance Company (P235 Issue Age continued) Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $37.44 $39.96 $42.48 $44.88 $ Foreign Travel Emergency: Age: Under 65 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 85

86 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P236 First-Year Commission: 24% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - High Deductible Plan Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $2, $2, $2, $2, $2, , , , , , , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. Rates effective January

87 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P236 First-Year Commission: 24% Waiting Period: None Premiums are based on issue age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - High Deductible Plan Age Area 1 Area 2 Area 3 Area 4 Area 5 Under 65 $2, $2, $2, $2, $2, , , , , , , , , , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. Rates effective January

88 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P237 First-Year Commission: 24% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - Comprehensive Plan* Annual Premium - Comprehensive Plan with Deductible Discount Rider** Area 1 Area 1 Age Amount Age Amount Under 65 $4, Under 65 $2, , , , , , , , , , , Area 2 Area 2 Under 65 $4, Under 65 $2, , , , , , , , , , , Area 3 Area 3 Under 65 $4, Under 65 $3, , , , , , , , , , , Rates effective January

89 Physicians Mutual Insurance Company (P237 Attained Age continued) Annual Premium - Comprehensive Plan* Annual Premium - Comprehensive Plan with Deductible Discount Rider** Area 4 Area 4 Age Amount Age Amount Under 65 $5, Under 65 $3, , , , , , , , , , , Area 5 Area 5 Under 65 $5, Under 65 $3, , , , , , , , , , , * Includes all basic policy benefits and also provides coverage for Part A deductible, Part B deductible, Part B excess charges, Additional Home Health Care, and Foreign Travel Emergency. ** The Deductible Discount Rider applies a $2,000 calendar year deductible to the Comprehensive Policy benefits for the first four calendar years of the policy. Beginning with the fifth calendar year, Comprehensive Policy benefits are payable in full with no deductible. Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 89

90 Physicians Mutual Insurance Company 2600 Dodge Street Omaha, NE ( Consumer Service Telephone No Form No. P237 First-Year Commission: 24% Waiting Period: None Premiums are based on issue age. Area 1: Zip Codes 538, Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549 Area 3: Zip Codes Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95) Area 5: Zip Codes 531 except for those listed above and 532, 534 Annual Premium - Comprehensive Plan* Annual Premium - Comprehensive Plan with Deductible Discount Rider** Area 1 Area 1 Age Amount Age Amount Under 65 $4, Under 65 $2, , , , , , , , , , , Area 2 Area 2 Under 65 $4, Under 65 $2, , , , , , , , , , , Area 3 Area 3 Under 65 $4, Under 65 $3, , , , , , , , , , , Rates effective January

91 Physicians Mutual Insurance Company (P237 Issue Age continued) Annual Premium - Comprehensive Plan* Annual Premium - Comprehensive Plan with Deductible Discount Rider** Area 4 Area 4 Age Amount Age Amount Under 65 $5, Under 65 $3, , , , , , , , , , , Area 5 Area 5 Under 65 $5, Under 65 $3, , , , , , , , , , , * Includes all basic policy benefits and also provides coverage for Part A deductible, Part B deductible, Part B excess charges, Additional Home Health Care, and Foreign Travel Emergency. ** The Deductible Discount Rider applies a $2,000 calendar year deductible to the Comprehensive Policy benefits for the first four calendar years of the policy. Beginning with the fifth calendar year, Comprehensive Policy benefits are payable in full with no deductible. Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 91

92 Reserve National Insurance Company 601 East Britton Road Oklahoma City, OK (reservenational.com) Consumer Service Telephone No Form No. MCS-WI First-Year Commission: 19% Waiting Period: 6 Months Premiums are based on attained age. Area 1: Zip Codes Area 2: Zip Codes 537, 543 Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Rates effective January

93 Reserve National Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $55.75 $49.15 $60.15 $52.45 $67.90 $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $60.15 $52.45 $64.60 $55.75 $72.85 $

94 Reserve National Insurance Company (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $38.65 $33.10 $41.40 $35.35 $46.35 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Discount offered for Electronic Funds Transfer (EFT) premium payment. 94

95 Standard Life and Accident Insurance Company 1 Moody Plaza Galveston, TX ( Consumer Service Telephone No Form No WI First-Year Commission: 20% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Zip Codes 534, 540, Area 3: Zip Codes , , 549 Area 4: Zip Code 546 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $5, Under 65 $8, $7, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $6, $6, , , , , , , , , , , , , , , , , , , , , Rates effective January

96 Standard Life and Accident Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Age Male Female Male Female Under 65 $1, $1, $1, $1, Area 3 Area 4 Age Male Female Male Female Under 65 $1, $ $ $ Part B Deductible ($147): Age: Under 65 $ Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $

97 Standard Life and Accident Insurance Company (continued) Part B Excess Charges: (continued) Area 3 Area 4 Age Male Female Male Female Under 65 $ $ $ $ Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Area 3 Area 4 Age Male Female Male Female Under 65 $ $ $ $ Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female Under 65 $93.04 $87.14 $79.75 $

98 Standard Life and Accident Insurance Company (continued) Foreign Travel Emergency: (continued) Area 3 Area 4 Age Male Female Male Female Under 65 $75.32 $70.54 $70.89 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and

99 Standard Life and Accident Insurance Company 1 Moody Plaza Galveston, TX ( Consumer Service Telephone No Form No. 2010WH-1106-WI First-Year Commission: 20% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Zip Codes 534, 540, Area 3: Zip Codes , , 549 Area 4: Zip Code 546 Annual Premium - High Deductible Plan Area 1 Area 2 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $1, $1, , , Area 3 Area 4 Age Male Female Age Male Female Under 65 $1, $1, Under 65 $1, $1, You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Rates effective January

100 Standard Life and Accident Insurance Company (continued) Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and

101 State Farm Mutual Automobile Insurance Company One State Farm Plaza Bloomington, IL ( Consumer Service Telephone No. Contact Local State Farm Agent Form No HWI First-Year Commission: 16% Waiting Period: None Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Under 65 $4, Under 65 $6, , , , , , , , , , , Area 2 Area 2 Age Amount Age Amount Under 65 $4, Under 65 $5, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $1, $1, Rates effective January

102 State Farm Mutual Automobile Insurance Company (continued) Part B Deductible ($147): Not offered Part B Excess Charges: Age Area 1 Area 2 Under 65 $48.00 $ Additional Home Health Care: Age Area 1 Area 2 All $30.00 $28.00 Foreign Travel Emergency: Age Area 1 Area 2 All $13.00 $12.00 Different premiums for each age between age 65 and

103 Sterling Life Insurance Company P.O. Box 5348 Bellingham, WA ( Consumer Service Telephone No Form No. WI STD BASIC (09/11) First-Year Commission: 12% Waiting Period: None Premiums are based on attained age. Area 1: Brown, Calumet, Fond du Lac, Kewaunee, La Crosse, Oconto, Outagamie and Sheboygan counties Area 2: Adams, Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Clark, Columbia, Crawford, Dane, Dodge, Door, Douglas, Dunn, Eau Claire, Florence, Forest, Grant, Green, Green Lake, Iowa, Iron, Jackson, Jefferson, Juneau, Lafayette, Langlade, Lincoln, Manitowoc, Marathon, Marinette, Marquette, Menominee, Monroe, Oneida, Pepin, Polk, Portage, Price, Richland, Rock, Rusk, Sauk, Sawyer, Shawano, Taylor, Trempealeau, Vernon, Vilas, Walworth, Washburn, Waupaca, Waushara, Winnebago and Wood counties Area 3: Kenosha, Milwaukee, Ozaukee, Pierce, Racine, St. Croix, Washington and Waukesha counties Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Rates effective January

104 Sterling Life Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): Male Female For all ages $ $ Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $63.22 $56.03 $61.79 $56.03 $77.60 $

105 Sterling Life Insurance Company (continued) Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $93.41 $ $93.41 $ $ Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $38.78 $34.50 $40.24 $35.93 $48.86 $ Rates for tobacco users are higher outside of open enrollment period. 105

106 Thrivent Financial for Lutherans 4321 North Ballard Road Appleton, WI ( Consumer Service Telephone No Form No. M-MW-MSWI (10) First-Year Commission: 12% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , 534 Area 2: Zip Codes 535, Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $4, Under 65 $5, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ Rates effective January

107 Thrivent Financial for Lutherans (Attained Age continued) Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Under 65 $ $ Additional Home Health Care: Age Area 1 Area 2 Under 65 $55.00 $ Foreign Travel Emergency: Age Area 1 Area 2 Under 65 $65.00 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. 107

108 Thrivent Financial for Lutherans 4321 North Ballard Road Appleton, WI ( Consumer Service Telephone No Form No. M-MW-MSWI (10) First-Year Commission: 12% Waiting Period: None Premiums are based on issue age. Area 1: Zip Codes , 534 Area 2: Zip Codes 535, Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $4, Under 65 $5, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ Rates effective January

109 Thrivent Financial for Lutherans (Issue Age continued) Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Under 65 $ $ Additional Home Health Care: Age Area 1 Area 2 Under 65 $55.00 $ Foreign Travel Emergency: Age Area 1 Area 2 Under 65 $65.00 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. 109

110 United American Insurance Company 3700 South Stonebridge Drive P.O. Box 8080 McKinney, TX ( Consumer Service Telephone No Form No. MC4810 First-Year Commission: 22% Waiting Period: 60 Days Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Male Female Under 65 $ $ Part B Deductible ($147): $ for all ages Part B Excess Charges: Age Male Female Under 65 $16.00 $ Rates effective January

111 United American Insurance Company (continued) Additional Home Health Care: Male Female For all ages $10.00 $9.00 Foreign Travel Emergency: Age Male Female Under 65 $ 2.00 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and

112 UnitedHealthcare Insurance Company (SecureHorizons) P.O. Box 6072 Cypress, CA Consumer Service Telephone No Form No. IMS-POL-WI First-Year Commission: 2% Waiting Period: None Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2, Under 65 $3, , , , , , , , , , , Area 2 Area 2 Under 65 $2, Under 65 $2, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ No Longer Marketed May 1, 2015 Part B Deductible ($147): $ for all ages, all areas Rates effective January

113 UnitedHealthcare Insurance Company (SecureHorizons continued) Part B Excess Charges: Age Area 1 Area 2 Under 65 $37.29 $ Additional Home Health Care: Age Area 1 Area 2 Under 65 $37.65 $ Foreign Travel Emergency: Age Area 1 Area 2 All $42.46 $38.24 Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. No Longer Marketed May 1,

114 UnitedHealthcare Insurance Company (SecureHorizons) P.O. Box 6072 Cypress, CA Consumer Service Telephone No Form No. IMS-POL-WI First-Year Commission: 2% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2, Under 65 $2, , , , , , , , , , , Area 2 Area 2 Under 65 $1, Under 65 $2, , , , , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. No Longer Marketed May 1, 2015 Rates effective January

115 UnitedHealthcare Insurance Company (SecureHorizons continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2, Under 65 $2, , , , , , , , , , , Area 2 Area 2 Under 65 $2, Under 65 $2, , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Not covered Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Under 65 $37.29 $ No Longer Marketed May 1,

116 UnitedHealthcare Insurance Company (SecureHorizons continued) Additional Home Health Care: Age Area 1 Area 2 Under 65 $37.65 $ Foreign Travel Emergency: Age Area 1 Area 2 All $42.46 $38.24 Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. No Longer Marketed May 1,

117 Western Catholic Union 510 Maine Street Quincy, IL ( Consumer Service Telephone No Form No. WCUMSBAS-WI 08/2014 Waiting Period: None First-Year Commission: 28% maximum Premiums are based on attained age. Area 1: Zip Codes , Area 2: Zip Codes 530 (all others), 531(all others), 535, 537, 538, 544, 549 Area 3: Zip Codes 530(05,07,08,12,17,22,24,33,37,45,46,51,52,72,76,89,92,97), 531(02,04,08-10,22,26,29,30,32,40-44,46,50,51,54,58,59,71,72,77,82,86-89,94), 532, 534 Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

118 Western Catholic Union (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $80.40 $69.96 $88.44 $76.92 $96.48 $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $42.60 $37.08 $46.92 $40.80 $51.12 $

119 Western Catholic Union (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $28.68 $24.96 $31.68 $27.60 $34.44 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Multi-policy household discount offered. 119

120 Wisconsin Physicians Service Insurance Corporation 1717 West Broadway P.O. Box 8190 Madison, WI ( Consumer Service Telephone No or Form No First-Year Commission: 15% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes (Milwaukee area and southeastern Wisconsin) 530(02,04,05,07,08,12,17,18,21,22,24,25,27-30,33,37,40,41,45,46,51-56,58,60,64,66-69,71,72,74,76,77,80,86,87,89,90,92,95-97), 531(01-13,16-19,22-24,26,27,29-36,39-46,49-55,58-75,77,79-83,85-89,92-94,96-99), 532, 534 Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ Rates effective March

121 Wisconsin Physicians Service Insurance Corporation (continued) Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Age Area 1 Area 2 Under 65 $ $ Additional Home Health Care: Foreign Travel Emergency: $24.00 for all ages, all areas $18.00 for all ages, all areas Part B copayment or coinsurance rider offered. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 121

122 Wisconsin Physicians Service Insurance Corporation 1717 West Broadway P.O. Box 8190 Madison, WI ( Consumer Service Telephone No or Form No First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes (Milwaukee area and southeastern Wisconsin) 530(02,04,05,07,08,12,17,18,21,22,24,25,27-30,33,37,40,41,45,46,51-56,58,60,64,66-69,71,72,74,76,77,80,86,87,89,90,92,95-97), 531(01-13,16-19,22-24,26,27,29-36,39-46,49-55,58-75,77,79-83,85-89,92-94,96-99), 532, 534 Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $1, Under 65 $1, * * 70 1, , , , , , , , Area 2 Area 2 Under 65 $1, Under 65 $1, * * 70 1, , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. *Contact company regarding rates for ages Rates effective March

123 Wisconsin Physicians Service Insurance Corporation (continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $1, Under 65 $1, ,188.72* 65 1,212.72* 70 1, , , , , , , , Area 2 Area 2 Under 65 $1, Under 65 $1, ,080.60* 65 1,104.60* 70 1, , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Additional Home Health Care: Foreign Travel Emergency: Not covered Not covered Not covered Not covered Not covered Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. *Contact company regarding rates for ages

124 GROUP MEDICARE SUPPLEMENT POLICIES TRADITIONAL INSURERS This listing includes group plans offered through associations. You must be a member of that association in order to purchase the plan. 124

125 Group Policy, Traditional Insurer UnitedHealthcare Insurance Company (AARP) P.O. Box 1017 Montgomeryville, PA ( Consumer Service Telephone No Form No. MDMW 0838, MDNW 0839, CRMD 05, CRMD 06, CRMD 07, CRMD 14, MAMW 0840, MANW 0841, CRMA 08, CRMA 09, CRMA 10, CRMA 15 First-Year Commission: $300 Maximum Waiting Period: 3 Months See enrollment discount. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Adams, Barron, Bayfield, Brown, Chippewa, Clark, Columbia, Dane, Door, Eau Claire, Florence, Fond du Lac, Forest, Green Lake, Iron, Juneau, Lafayette, Langlade, Lincoln, Manitowoc, Marathon, Marinette, Marquette, Menominee, Oconto, Oneida, Outagamie, Pepin, Portage, Rock, Sauk, Sawyer, Sheboygan, St. Croix, Taylor, Vilas, Walworth, Washburn, Waupaca, Waushara, Winnebago, and Wood counties Area 3: Ashland, Buffalo, Burnett, Calumet, Crawford, Dodge, Douglas, Dunn, Grant, Green, Iowa, Jackson, Jefferson, Kewaunee, La Crosse, Monroe, Pierce, Polk, Price, Richland, Rusk, Shawano, Trempealeau, and Vernon counties Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $4, Under 65 $5, , , , , , , , , , , Area 2 Area 2 Under 65 $3, Under 65 $4, , , , , , , , , , , Rates effective January

126 Group Policy, Traditional Insurer UnitedHealthcare Insurance Company (AARP continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Amount Age Amount Under 65 $3, Under 65 $4, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260), Part B Excess Charges, and Foreign Travel Emergency: Age Area 1 Area 2 Area 3 Under 65 $ $ $ Part B Deductible ($147): Age Area 1 Area 2 Area 3 Under 65 $ $ $ Additional Home Health Care: Age Area 1 Area 2 Area 3 Under 65 $ $ $ Individuals applying for the UnitedHealthcare Group Medicare Supplement Policy must be members of AARP. Enrollment discount for age 65 and 70: insureds who are within 3 years of their 65th Birthday or Part B effective date, if later; insureds between 3 years and less than 6 years of their 65th Birthday or Part B effective date, if later, and meet underwriting requirement. The enrollment discount decreases by 3% each year until the enrollment discount is 0%. 126

127 Group Policy, Traditional Insurer UnitedHealthcare Insurance Company (AARP continued) Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Multi-policy household discount offered. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. Please contact Customer Service Toll Free number at for your premium rate and to determine if you are eligible for any available discounts. 127

128 MEDICARE SUPPLEMENT POLICIES MEDICARE SELECT Medicare select policies are offered by HMOs and PPOs. HMOs are prepaid health plans. You pay the HMO a set premium each month for all covered services. You must use the doctors and hospitals that are connected to the plan. There is less paperwork if you join an HMO. PPOs will provide reduced benefits if you receive care from providers who are not connected to the plan. All Medicare select policies contain similar benefits and these benefits are included in the basic policy. 128

129 Dean Health Plan, Inc Deming Way Madison, WI Medicare Select Consumer Service Telephone No or TTY 711 Form No Waiting Period: None First-Year Commission: None Premiums are based on attained age. Area: Adams, Columbia, Crawford, Dane, Dodge, Fond Du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Kenosha, Lafayette, Marquette, Racine, Richland, Rock, Sauk, Vernon, Walworth, Washington, and Waukesha counties; Zip Codes 53014, 53049, 54923, 54930, 54943, 54960, 54964, 54966, 54971, 54979, Annual Premium - Basic Policy Age Amount Under 65 $2, , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

130 Group Health Cooperative of South Central Wisconsin 1265 John Q. Hammons Drive Madison, WI ( Medicare Select Consumer Service Telephone No Form No. CSC (08/14)C First-Year Commission: 10% Waiting Period: None Premiums are based on issue age. Area: Dane, Jefferson, Green, Lafayette, Rock, Columbia, Dodge, Iowa, Sauk, Adams, Richland, Vernon, and Juneau counties Annual Premium - Basic Policy Age Amount Under 65 $2, , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Different premiums for each age between age 65 and 85. Rates effective January

131 Health Tradition Health Plan 1808 East Main Street Onalaska, WI ( Medicare Select Consumer Service Telephone No or Form No. 221HTH207 First-Year Commission: 15% Waiting Period: None Premiums are based on attained age. Area: Buffalo, Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Richland, Trempealeau, and Vernon counties Annual Premium - Basic Policy Age Amount Under 65 $2, , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

132 MercyCare HMO, Inc. 580 North Washington Street P.O. Box 550 Janesville, WI ( Medicare Select Consumer Service Telephone No Form No. MCSPNOV2013 First-Year Commission: None Waiting Period: None Premiums are not based on age. (Area 1) Premiums are based on attained age. (Area 2) Area 1: Rock, Walworth, and Green counties Area 2: Jefferson county Annual Premium - Basic Policy Area 1 Area 2 Age Amount Amount Under 65 $1, $2, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

133 Physicians Plus Insurance Corporation 2650 Novation Parkway, Suite 400 Madison, WI (pplusic.com) Medicare Select Consumer Service Telephone No or Form No. P First-Year Commission: $20.05 Waiting Period: None Premiums are based on issue age. Area: Columbia, Dane, Dodge, Grant, Green, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock, Sauk, and Vernon counties Annual Premium - Basic Policy Age Male Female Under 65 $2, $2, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

134 Security Health Plan of Wisconsin, Inc North St. Joseph Avenue Marshfield, WI ( Medicare Select Consumer Service Telephone No Form No. INS Waiting Period: None First-Year Commission: $12.00 per month Premiums are based on attained age. Area: Adams, Ashland, Barron, Bayfield, Burnett, Chippewa, Clark, Douglas, Dunn, Eau Claire, Forest, Iron, Jackson, Juneau, Langlade, Lincoln, Marathon, Monroe, Oneida, Pepin, Portage, Price, Rusk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waupaca, Waushara and Wood counties Annual Premium - Basic Policy Age Amount Under 65 $3, , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. Rates effective January

135 Unity Health Plans Insurance Corporation 840 Carolina Street Sauk City, WI ( Medicare Select Consumer Service Telephone No Form No. UH00804 First-Year Commission: $ Waiting Period: 180 Days Premiums are based on attained age. Area: Adams, Columbia, Crawford, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock, Sauk, Vernon, Walworth, and Waushara counties Annual Premium - Basic Policy Age Male Female Under 65 $3, $2, , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In basic policy In basic policy In basic policy In basic policy Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

136 MEDICARE COST INSURANCE Medicare cost insurance is a special arrangement between the federal Centers for Medicare & Medicaid (CMS) and certain HMOs. The HMO agrees to provide Medicare benefits. The HMO may provide additional benefits at additional cost. Medicare cost insurance will only pay full supplemental benefits if covered services are obtained through HMO plan providers. You must live in the plan service area to apply for Medicare cost insurance. The HMO plan providers are selected by the HMO. In a Medicare cost insurance policy you are not locked in to the HMO plan providers for your Medicare benefits. Medicare will still pay its share of approved charges if the services you receive outside the network are services covered by Medicare. If you go to a health care provider who does not belong to your HMO without a referral from your HMO physician, you will pay for all Medicare deductibles and copayments. The HMO will not provide supplemental benefits. 136

137 Medicare Cost Insurance Dean Health Plan, Inc Deming Way Madison, WI Consumer Service Telephone No , TTY 711 Form No. H5264_ANOC-EOCE_0814 H5264_ANOC-EOCB_0814 H5264_ANOC-EOCSV_0814 Waiting Period: None First-Year Commission: None Premiums are not based on age. Area: Columbia, Dane, Dodge, Grant, Iowa, Jefferson, Rock, and Sauk counties Type of Policy Annual Premium Amount Enhanced $1, Basic 1, Shared Value Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In all policies In all policies In Enhanced and Shared Value policies In Enhanced and Shared Value policies Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

138 Medicare Cost Insurance HealthPartners Insurance Company rd Avenue South P.O. Box 1309 Minneapolis, MN healthpartners.com/medicare Consumer Service Telephone No , TTY Form No. EOC COST-WI-BA-RXD EOC COST-WI-BA EOC COST-WI-B Waiting Period: None First-Year Commission: Contact plan Premiums are not based on age. Area: Barron, Burnett, Douglas, Dunn, Pierce, Polk, St. Croix, and Washburn counties Annual Premium Type of Policy Amount WI Freedom Balance with Rx $ WI Freedom Balance WI Freedom Basic Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In all policies In all policies In WI Freedom Balance with Rx and WI Freedom Balance policies In WI Freedom Balance with Rx and WI Freedom Balance policies Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

139 Medicare Cost Insurance Medica Insurance Company 401 Carlson Parkway Minnetonka, MN ( Consumer Service Telephone No Form No. WI-PRI-EOC Waiting Period: None First-Year Commission: Contact Plan Premiums are not based on age. Area: Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix, and Washburn counties Type of Policy Annual Premium Amount Enhanced Policy $1, Basic Policy Value Policy Thrift Policy Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In all policies In all policies In all policies N/A Part B Excess Charges is not needed as long as you use plan providers. Rates effective January

140 Medicare Cost Insurance Medical Associates Clinic Health Plan of Wisconsin 1605 Associates Drive, Suite 101 Dubuque, IA ( Consumer Service Telephone No Form No. H5256 PBP 004_MAHP 666 First-Year Commission: $18.00 H5256 PBP 002_MAHP 665 H5256 PBP 001_MAHP 664 Waiting Period: None Premiums are not based on age. Area: Crawford, Grant, Iowa, and Lafayette counties Annual Premium Type of Policy Amount Freedom Plan $1, Community Plan 1, Smart Plan 1, Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Additional Home Health Care: Foreign Travel Emergency: In all policies In all policies In all policies In all policies Part B Excess Charges is not needed as long as you use plan providers. Rates effective January